Form C-27 - Nys Workers Compensation Board

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NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
CHECK TYPE OF DOCTOR
State of New York
THIS AGENCY EMPLOYS AND SERVES
PHYSICIAN
CHIROPRACTOR
PEOPLE WITH DISABILITIES WITHOUT
WORKERS' COMPENSATION BOARD
DISCRIMINATION.
PODIATRIST
PSYCHOLOGIST
MEDICAL PROOF OF CHANGE IN CONDITION IN SUPPORT OF APPLICATION FOR REOPENING OF CLAIM FOR
WORKERS' COMPENSATION, VOLUNTEER FIRE FIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' BENEFITS
This report must be signed personally by the attending doctor or by some other doctor having knowledge of the facts. If doctor renders treatment in a case, including treatment for an
occupational disease, C-4 (or PS-4 by psychologists) reports must also be filed. File the signed original of each report with (1) CHAIR, WORKERS' COMPENSATION BOARD at the
centralized mailing address listed above and file a signed copy with (2) the INSURANCE CARRIER, if known, or the EMPLOYER.
ANSWER ALL QUESTIONS FULLY - TYPEWRITER OR COMPUTER PREPARATION IS STRONGLY RECOMMENDED
CLAIMANT'S SOCIAL
WCB CASE NO.
CARRIER CASE NO.
ADDRESS WHERE INJURY OCCURRED
DATE OF INJURY AND TIME
SECURITY NO.
(If Known)
(If Known)
(City, Town or Village)
ADDRESS
NAME
First Name
Middle Initial
Last Name
Age
INJURED
APT. NO.
PERSON*
EMPLOYER
(at the time of
accident)
INSURANCE
CARRIER
* If patient claims that injury occurred while performing assigned duty as a Volunteer Firefighter or Volunteer Ambulance Worker,
VF/VAW
show as EMPLOYER the city, town, village, district or ambulance company against which the claim is made and enter "x" here:
(a) When did YOU first treat claimant?
(b) last treat claimant?
(c) Are you still treating?
1.
State in patient's own words how accident or injury occurred:
2.
Did you communicate with claimant's last attending doctor to ascertain medical findings present at time of discharge?
3.
State the present pathology which in your opinion warrants a reopening of this case:
4.
5.
Describe treatment or apparatus now necessary:
6.
Describe any present disability or condition not present at time case was last closed:
Is there any permanent defect?
If so, what is percentage loss or loss of use?
7.
In your opinion was the accident or injury as above described a competent producing cause for the present findings and complaints?
8.
9.
Is claimant working?
(a) Able to do usual work?
When?
(b) Able to do any work?
When?
(c) Specify work limitations, if any:
10.
Name of latest employer
Last day worked
Address
Typed or Printed Name of Attending Doctor
Address
Telephone No.
W.C.B. Authorization No.
W.C.B. Rating Code
PHYSICIANS COMPLETE THE FOLLOWING
I state that I am a physician, authorized by law to practice in the State of New York, am not a party to this proceeding, am the physician who subscribed to the above (or attached)
report, have read the name and know the contents thereof; that the same is true to my knowledge, except as to the matters stated to be on information and belief, and as to those
matters I believe it to be true. Affirmed as true under the penalty or perjury.
Written Signature (Facsimile Not Accepted)
Date
IMPORTANT: BY LAW CHIROPRACTOR'S, PODIATRIST'S AND PSYCHOLOGIST'S REPORTS MUST BE SWORN TO BEFORE A NOTARY PUBLIC.
State of New York
)
ss:
County of
, being duly sworn, deposes and says:
)
That (s)he is the
, duly licensed in the State of New York, who subscribed to the above (or attached) report; and that (s)he has read the
same and knows the contents thereof; that the same is true to the knowledge of deponent, except as to the matters stated to be on information and belief, and as to
those matters (s)he believes it to be true.
Subscribed and sworn before me this
day of
,
(Signature of Notary Public)
C-27
ANSWER ALL QUESTIONS, AVOID USE OF INDEFINITE TERMS. - See Reverse for HIPAA Notice
(1-11)
Statewide Fax Line: 877-533-0337

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